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APPLICATION FOR PERMIT
DIG SAFE NUMBER
City or Town
Date
Start Date:
in accordance with the provisions of M.G.L. Chapter 148, as provided in Section application is hereby made
by
_ —(F�jll name of person,-Firm or poration)
AddressA
(Street or P.O.Box)(City orTown)_.--
x
For permission to (state clearly purpose for which permit is requested)�'-'e.
—'' KX, ,
Name.of competent operator (if Applicable) ` ����'��°�r 9�a�% �'" Cent. No. z� 2 2
Date Issued-rejected �7— By
(Signature of Applicant)
Date of expiration ��®it Fee $ Paid Due
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PERMIT
-ity or Town D1G SAFE NUMBER
late_
:StaFtDate:
ermit Number (if applicable)
i accordance with the provisions of M.G.L. Chapter 148, as provided in this permit is granted
i
(Full name of person,Firm or Corporation)
it QIYY/ l E r G� % /ion f��.i� � a/ ,� �
estrictions:
(Give location by street and no.,or describe In such manner as to provide adequate idenidication of location) .
ve Paid $ r-
gnature of,Official Granting Permit � - yL' Title
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